Why Social Determinants of Health raise the question, ‘Now What?’

Information technology has the potential to enable effective sharing of data that helps facilitate effective delivery of services.

From Hippocrates to Doogie Howser, physicians both real and fictional have understood that improving the health of their patients requires an inquiry deeper than the sciences of physical medicine. Great physicians look beyond the physical variables to a person's social context—the state of their housing, food, transportation, family life and other matters that contribute to at least half of a person’s health.

Unfortunately, the impact of such a broader inquiry doesn’t get very far. The valley between social and medical funding in our country has meant that doctors have historically done little more for a patient with overbearing social issues than to hand them a list of community nonprofits and wish them good luck.

Today, that’s changing. Social determinants of health (SDOH) are at last being given the recognition they deserve, thanks largely to their central role in achieving value-based care. One example of the increased recognition is the creation of ICD-10 “Z codes,” enabling providers to document and communicate SDOH issues within the electronic health record. Initiatives such as the Social Interventions Research & Evaluation Network (SIREN) Gravity Project are focused on identifying and expanding medical codes across multiple standards systems to improve providers’ capacity to document and communicate SDOH screening, diagnoses, and related interventions.

Yet once SDOH issues are identified, most providers are still left with a difficult question: Now what?

The answer to that question is rapidly coming into focus thanks to the concerted effort of a small number of communities, from Oakland, Calif., to Troy, N.Y., where organizations ranging from food pantries to homeless shelters, hospitals to health plans have partnered to create robust technology-enabled networks connecting social services with medical care. The effort has not been without barriers.

Most medical providers understand that there are many individual social care providers within their communities that can address specific needs. For patients who can’t afford healthy food, federally funded food assistance programs exist in all states and most communities. For those who lack reliable transportation to medical appointments or the grocery store, faith-based and other charitable organizations sometimes offer free transportation. There are also multiple options for housing, including temporary housing in shelters, and Section 8 housing for low-income people.

Unfortunately, those options are disjointed, with little information available about their responsiveness and the quality of their work, and no easy method (in most cases) of reporting back on the results they have achieved for individuals referred to them, or even that services were successfully provided. In most communities, referring a patient to a social care provider is little more than a blind handoff with the hope that the organization has the time, knowledge and resources to address the problem.

That approach may very well be successful—or it could be a dead end—we don’t have a good way to know which. Ideally, medical care providers should not simply refer an individual to a social care provider and consider their part finished. Both sides need to work together to track referrals and report on outcomes, preferably as part of an organized network, so they can make sure that nobody falls through the cracks.

Building a living network between medical and social care providers in the community is therefore vital to addressing social determinants of health. Helping in that effort is a new generation of technology-enabled networks connecting medical and social care providers together. These networks create a platform both sides can use to track and manage referrals, eliminating the need for faxes and sticky notes. They also make it easier for social care providers to track and report the outcomes of their interventions in real time, demonstrating how they are keeping individuals healthier and reducing costs: making a business case for the work they have always done—and ideally will continue to do.

Some examples of states, managed care organizations (MCOs) and social care providers with programs underway that aim to build such networks include:

• Arizona, which requires coordination of community resources such as housing and utility assistance under its managed long-term services and supports contract.

• The District of Columbia, which encourages MCOs to refer beneficiaries with three or more chronic conditions to the “My Health GPS” Home Health program.

• Louisiana, where plans are required to screen for gambling addiction and tobacco use, and referrals to the Special Supplemental Nutrition Program for Women, Infants and, Children are required.

• Nebraska, which requires MCOs to have staff trained on social determinants of health and to be familiar with community resources.

• North Carolina, which has established NCCARE360, a statewide closed-loop referral network between social care providers, MCOs and medical care providers.

• Troy, N.Y., where our organization, Alliance for Better Health, has spent five years creating and maintaining a network of high-performing social care providers and connecting them with medical providers and MCOs.

The advantages of a technology-enabled network of social and medical care providers and health plans are profound. With the click of a button, health plan staff and medical providers can make direct electronic referrals, instantly see whether individuals engage with the social care provider, and track the outcomes. If an individual fails to receive the help they need, then the system can identify them and notify participants that a secondary intervention may be needed. The network also makes it easy for social care providers to refer individuals to primary care, or a particular health system.

Much like supply chain management, a technology-enabled network of organizations across the continuum creates the means to enable payment models between medical care providers and social care providers. Importantly, the network enables measurement and analysis of the progress, performance and outcomes delivered by all parties involved in a fully accountable network.

Most organizations (and people) don’t like change and are often resistant to it. A framework such as the one in place in our region is ideally a shared, horizontally integrated, community-wide resource. Like streetlights and telephone wires, it’s not a competitive advantage for one health system, health plan, or physician practice. In this model, moving toward value-based care holds the potential for social care providers to benefit tremendously so they can offer better services to more of the people who need them.

The even better news is that they don’t have to figure out how to manage it on their own. Organizations like ours have already spent years building the relationships that bring organizations together in a network and deploying the technology foundation to make the network work. By taking advantage of these new networks and the underlying technologies and services they offer, social and medical care providers can exponentially, and almost instantly, improve their ability to send and receive referrals as well as track and report on the results they’re achieving—creating a win-win for all involved.

The importance of SDOH issues and their impact on the health of individuals and populations can hardly be overstated. It is good that government and the health care industry as a whole has recognized their importance, and that a plethora of agencies and organizations are standing by to help them answer the “Now what?” question. But attempting to address these issues in a piecemeal, vertical (within a health system or health plan) or ad hoc manner will have limited success. By organizing medical and social care providers into a formal social care network that serves everyone, with open communication, two-way referrals and detailed quality reporting, we can do far better by our most vulnerable populations. And in the process help to lower the overall cost of care.

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